Secondary Insurance Prescription Drug Claim Form - Blue Cross Blue Shield Of Alaska printable pdf download

P.O. Box 240609

Anchorage, AK 99524-0609

800-508-4722

800-842-5357 TDD for the hearing impaired

Secondary Insurance

Prescription Drug Claim Form

Please follow instructions carefully.

If all boxes are not completed, there could be a delay in processing.

Please list your prescription drugs below in date order and submit on a monthly basis.

All drugs listed must be for same person and same pharmacy. Please use a separate form for each person, each pharmacy.

Receipts must be attached to this form for all prescriptions. Please tape (do not staple) to reverse side or another sheet of paper.

Cash register receipts are not acceptable.

Explanation of benefits from primary insurance or pharmacy receipt indicating copay amount from primary coverage must be

attached.

Subscriber (Employed) Name: __________________________

Patient Name: ________________________________________

___________________________________________________

____________________________________________________

ID Number: _________________________________________

Relationship to Subscriber: ______________________________

Mailing Address: _____________________________________

Pharmacy Name: _____________________________________

___________________________________________________

Address: ____________________________________________

Subscriber’s Employer:

(Group Number) _____________________________________

____________________________________________________

Please list your prescription drugs below in date order:

Balance after

Drug

Date of

Amount

Primary

Quantity

Name of

Prescription

Purchase

Charged

Ins. Benefits

Units/Days

Each Drug

Number

Prescribing Physician

Keep copy for your records (form and attachments)

I hereby certify that the above drugs were necessary for treatment of the illness/injury reported and were purchased for

the individual named above.

Signature (Subscriber) _____________________________________________________ Date __________/___________/_________

Please return this form to Premera Blue Cross Blue Shield of Alaska, P.O. Box 240609, Anchorage, AK 99524-0609.

If you have any questions, please call Premera Blue Cross Blue Shield of Alaska’s Customer Service

Toll free at 800-508-4722 ● 800-842-5357 TDD for the hearing impaired

015465 (07-2005)

An Independent Licensee of the Blue Cross Blue Shield Association

Secondary Insurance Prescription Drug Claim Form - Blue Cross Blue Shield Of Alaska

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